culture code

Have you had shifts or worked on committees where everything went smoothly? Closed loop communication happened, there was mutual respect among all the team members, and each individual felt empowered to give input even if it differed from what had already been said or done? You’ve probably also worked on shifts, in meetings, or participated in projects where it seemed like the team was falling apart, communicating on different wavelengths, and failing to have a shared understanding. You may feel like a great leader one day and a failure the next. The difference, according to The Culture Code, has everything to do with the culture of the team. In this 2018 book, Daniel Coyle explains what makes teams successful and how you can help create the culture necessary for all of your teams, committees, and groups to succeed.

Introduction

First, you need to understand the spaghetti challenge. It illustrates the problem with low-performing team culture. Researchers have experimented with diverse groups around the world in which they give 4-person groups a set of materials:

  • 20 pieces of uncooked spaghetti
  • 1 yard of transparent tape
  • 1 yard of string
  • 1 marshmallow

The teams are tasked with creating the tallest structure they can that will support the weight of the marshmallow. The shocking finding is that teams of lawyers, CEOs, and business students are routinely beat (by several inches) by groups of kindergarteners. When observing the teams in action, you might see the kindergarteners standing very close to each other, trying different things, not talking that much, not getting their feelings hurt if their idea isn’t used, and not afraid to disagree with another group member.

By contrast, the civilized conversation, planning, and rational discourse that the educated adult teams engage in mask what is actually going on. Instead of truly focusing on solving the problem, these groups are engaged in status management. The individuals are figuring out where they stand in the pecking order of the team, what the rules of engagement are, whether it’s safe to disagree with other members, etc. There are subtle competition and inefficiency that lead to towers of less than 10 inches for the business students compared with 26 inches for the kindergarteners! Imagine now that instead of building spaghetti tower, the goal is running a code and resuscitating a dying patient. Can you see how important having a high-functioning culture is for you team?

“Culture is a set of living relationships working toward a shared goal.”

Coyle researched companies, sports teams, military units, and schools around the world to discover the common characteristics of high performing teams. He presents 3 skills that are needed to build a culture from the ground up, starting with group connection, and then leading to purpose and action.


Skill 1 – Build Safety

“How signals of connection generate bonds of belonging and identity” 

The fundamental relationship between individuals in highly functional groups is not as teammate, colleague, or even friends, but as family. In studying successful groups, Coyle noted that the individuals felt a deep sense of belonging to the group, connection with each other, and of psychological safety.

Neuro-psychological studies have shown that we are strongly wired to sense and value belonging. Our prior survival probably depended on it! In a group of people, a “sense of belonging is easy to destroy and hard to build”. Even one ‘bad apple’ in a team can ruin the sense of belonging for one or more group members or even tank the whole team. This paradigm of team dynamics is highly relational rather than the transactional. There are 3 primary ways that members of a group send and receive belonging cues to each other.

  1. Energy – Individuals are engaged with the group
  2. Individualization – Each person is valued and his/her opinion listened to.
  3. Future orientation – There is a sense that the relationship has a future.

Even small cues and gestures can have big effects on our sense of belonging. Consider this experiment: In a group of 772 patients in Australia who had been admitted for a suicide attempt, half were sent a postcard that read: “Dear [name], It has been a short time since you were here at Newcastle Mater Hospital, and we hope things are going well for you. If you wish to drop us a note, we would be happy to hear from you. Best wishes, [name].” With just that small intervention, the group who received the notes had half the readmission rate of the control group over 2 years.

You might think the success of a team depends on the individual team members’ skills. However, to a great extent it depends on 5 specific factors that can predict with accuracy how well a team will perform:

  1. All team members both talk and listen.
  2. There is lots of eye contact and energy.
  3. The group members talk to each other in the group discussion, not just to the boss/leader.
  4. Team members talk with each other outside the group discussion.
  5. Group members bring ideas back from outside conversations or research to share with the team.

We are constantly receiving cues from each other about whether we belong, what our significance is to the other person, and whether we have a future together. It takes consistent, regular, and positive cues to build a culture. Belonging, Coyle writes, is “a flame that needs to be continually fed by signals of safe connection.”

As a practical example, if a nurse does not feel safe speaking up because the last time they did; they were met with frustration, anger, or cues that they didn’t belong, then the next time they notice a potential error or something that might have been overlooked, they may be less likely to speak up. If a trainee learns that when she asks questions she is met with derision or subtle cues that she isn’t smart enough, she may stop asking questions, thus limiting her learning opportunities. We have to create environments in which individuals experience psychological safety and belonging in order to work and learn well.

High functioning teams are not light-hearted, shallow groups where woodland creatures gambol around, the participants sing kumbaya, and there is always sunshine. In fact, great teams have enough psychological safety and belonging that they can give real, honest feedback and have difficult conversations. In great teams, feedback is given in a way that builds the sense of belonging rather than leads to alienation.

Research on feedback has shown the best feedback communicates or states: “I’m giving you these comments because I have very high expectations and I know that you can reach them.” The use of this feedback is discussed extensively in Carol Dweck’s book, Mindset. Feedback given in this way sends the message that you are getting the feedback because you are part of the group, not in spite of it, and that you have a future together, as you expect the person to improve.

Coyle argues strongly against the “feedback sandwich.” You may have received one of these delicacies or even been taught to serve them up: the positive feedback, then the negative, sometimes followed by another positive. However, the result of this feedback structure is that often that the positive feedback is perceived as trite, conciliatory dressing for the actual feedback, which is negative. Instead he suggests separating the two. Give negative/formative feedback when it is needed, but couch it in terms of belonging, relationship, and a shared mission or vision. Then give exuberant positive feedback when it is due.

In their 2019 Harvard Business Review article The Feedback Fallacy, Buckingham and Goodall explains why the culture of radical transparency and brutal feedback are counter-productive, and instead argue for noting and calling attention to the moment when someone does something well. “That, yes that!” is the way you can focus on the individual’s and group’s attention on something done well. In this way you can give timely, focused praise, rather than a vague, summative assessment at a later time.

Given our acute sensitivity to belonging cues, it is of utmost importance to set the tone of a group at the very start, or whenever a new member joins. The new member will quickly pick up on whether this is a hard-working group that cares about each other like family. Rather than if they are subtly back-stabbing, gossiping group focused on status management.


Skill 2 – Share Vulnerability

“How habits of mutual risk drive trusting cooperation.”

As a leader or a group member, or even the most junior member on a team, sharing vulnerability can be highly counterintuitive and uncomfortable. Leaders may feel the need to keep a stiff upper lip, to maintain the aura that they are in perfect control and are fully capable of handling everything. Junior members may feel they need to prove themselves and show that they can manage the workload or the responsibility. However, showing vulnerability and honesty can actually help build deep connection and also allow for process and performance improvement.

Being vulnerable, as Brené Brown expounds upon in her book Dare to Lead, does not mean indiscriminately sharing fears and shortcomings. Instead it means specifically being honest about your concerns about a project. Doing so in a way that can then allow other team members to chime in and offer ideas. She writes: “The courage to be vulnerable is not about winning or losing, it’s about the courage to show up when you can’t predict or control the outcome.” She argues that being vulnerable means “We must take off the armor, put down the weapons, show up, and let ourselves be seen.”

Sharing vulnerability can also mean taking an honest look at how things went. The Navy SEALs have a practice of honestly facing uncomfortable questions after a mission or training in an After-Action Review (AAR). During this time, they review what went well, what went poorly, and what they can improve. “They’re not real fun,” says one former SEAL operator, “still, they’re probably the most crucial thing we do together… because that’s where we figure out what really happened and how to get better.” Sharing our own vulnerability about what we are concerned about, or what we think could be improved creates an environment where others feel free to share their concerns as well.

In the ED this could take the form of a preparatory discussion in which the group leader asks for input from all the team-members, or a post-code debrief of what went well and what didn’t to improve for the next time. In a leadership group or committee, it could mean cultivating curiosity about others’ opinions and ideas. Creating connections among group members and their work, of asking specific, probing questions to help individuals move their ideas forward.

This second skill of sharing vulnerability is built on the first skill of creating psychological safety and belonging. Ideally it is the leader who should demonstrate vulnerability first. This sends the message that “It’s safe to tell the truth here”. For both of the first 2 skills, one way to develop them is through active, engaged listening. He suggests we should avoid the temptation of jumping in with our own ideas, and instead cultivate the habit of asking “Say more about that.”

Leaders should also ask for honest feedback. Coyle quotes Laszlo Bock, a former head of People analytics at Google who recommends leaders ask their group members for specific feedback in 3 areas:

  1. Name one thing that I currently do that you’d like me to continue to do?
  2. Is there one thing I don’t currently do frequently enough that you think I should do more often?
  3. What can I do to make you more effective?

For the skill of vulnerability, Coyle identifies key times when it is extremely critical to focus on the culture formation. They are at the time of the first expression of vulnerability, and at the first disagreement.


Skill 3 – Establish Purpose

“How narratives create shared goals and values”

The final skill is about establishing purpose and vision. Once you have a team that feels safe and shares a sense of belonging, the team will work together better if there is a shared goal and sense of what they are working towards. Your purpose should be concise, focused, and easy to remember. For example, would each of the individuals (faculty, nurses, staff) in your department articulate the same answers to the following questions: What is the mission of your group? To whom are you primarily responsible? What are the core values or guiding principles of your department?

Coyle gives several ideas for how to establish a purpose for your group:

  1. Rank your priorities. What are the primary things that are most important to your group or team? Is it the patients? The group-members? Or, is it the community or population? Is it the research subjects?
  2. Be clearer than you think you need to be. Ask group members what your vision is. Make sure they understand. See if you get the answers you think you have communicated.
  3. Decide on where you will aim for proficiency and where you will aim for creativity. This means define the areas where the team and team members need to be proficient in specific skills. But then also allow room and empowerment for them to be creative and solve problems in new ways. Allowing group members to have enough autonomy that they can be creative will mean allowing them enough autonomy to fail. He recommends you “make it safe to fail and to give feedback” and “celebrate hugely when the group takes initiative.”
  4. Embrace catchphrases. Cultures that have a sense of belonging often have a shared vocabulary. Think of this as the “in jokes” or language that you might use with a close friend. When you reference a quote or a Seinfeld episode, and your friend immediately knows what you’re talking about. Similarly, having sayings, terms, or “in” jargon that you all use can create that ever-important sense of belonging.
  5. Measure what matters. Don’t measure and publicize which clinician spends the least amount of time in each patient’s room if that is not one of your core values. You will get more of whatever actions you reinforce. By publicizing any given metric, you will reinforce that those are the important things your department or group is about. So be thoughtful and cautious about what you measure.
  6. Focus on bar-setting behaviors. It’s not enough to just have a long-term goal or big-picture vision, you need to identify specific behaviors that you want your team to have that will help get you toward that goal.

Summary

High functioning teams are ones that create a culture of psychological safety, where individuals can be vulnerable. Where there is a well-defined core mission. You can help create great culture in your team by consistently supplying belonging cues to others, engaging in active listening. While giving feedback in ways that reinforces belonging and high expectations and does not lead to shame and alienation.

If you aren’t sure how well your team is currently functioning, ask team members what the mission is. If there is a shared mission, you are doing well. Spend time observing members and see how much they are focused on problem solving versus status management. Consider interactions in the group: Does everyone talk? Does everyone listen? Are people free to disagree with the leader? Are they ashamed or ostracized for doing so? This book will give you principles you can use to diagnose the health of your teams. Allowing you to continuously do the hard work to improve them.

Additional references and further reading on this topic:

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Christina Shenvi, MD PhD
ALiEM Associate Editor
Assistant Professor
Assistant Residency Director
University of North Carolina
www.gempodcast.com
Christina Shenvi, MD PhD

@clshenvi

Emergency Medicine and Geriatrics trained, Assistant Residency Director, mother of 4, excited about #MedEd, #EM, #Geriatrics, and #FOAMed.